Affordable Care Act

The passage of the Affordable Care Act represents an historic change in the way health insurance has been handled in the United States. With political discourse about the act continuing to occupy public policy debates and the news media, this collection attempts to shed light on the impact of the policy on citizens and providers as well as examine how the ACA is affecting quality, access, and costs of care.

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Issue: Since 2001, long before the passage of the Affordable Care Act (ACA), the Commonwealth Fund Biennial Health Insurance Survey has examined health coverage and consumers' experiences buying insurance and using health care. Goals: To examine long-term trends and to make comparisons before and after passage of health reform. Methods: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: There have been dramatic improvements in people's ability to buy health plans on their own following the passage of the ACA. For adults with family incomes less than $48,500, uninsured rates dropped about 17 percentage points below their 2010 peak. Lower-income whites, blacks, and Latinos have experienced drops this large, though Latinos are uninsured at higher rates. Among working-age adults who had shopped for plans in the individual market and ACA marketplaces over the prior three years, the percentage who reported it was very difficult to find affordable plans fell by nearly half from 2010, prior to the ACA reforms, to 2016. Coverage gains are helping working-age Americans get the care they need: the number of adults who reported problems getting needed health care and filling prescriptions because of costs fell from a high of 80 million in 2012 to an estimated 63 million in 2016.

A major goal of the ACA was to give workers the ability to obtain insurance outside of their employment, so that they would not be tied to a job that doesn't meet their needs or fully utilize their skills due of their need for health insurance. The jump in voluntary part-time employment since the exchanges went into operation is an indication that the ACA has had this effect. This paper gives the breakdown of this increase by state. Presumably, if the ACA were repealed without some comparable or better system of insurance put in its place, these numbers should give an indication of how many people would again be forced to seek out full-time employment to get employer-provided health insurance, even though part-time work better fits their needs.

Before the Affordable Care Act (ACA), the landscape of the individual market looked much different than it does today, particularly for those in less than perfect health. For the most part, what state you lived in determined how easily you could purchase a health plan, the price you would pay, and what the plan would cover. Rules for insurers in the individual market varied from state to state, but in most states, if you had a pre-existing condition, you could be denied coverage, pay more, or have coverage for your pre-existing condition excluded from your health plan. As Congress debates repeal of the ACA and its protections for people with pre-existing conditions, many policymakers have called for greater state flexibility in insurance regulation than currently exists under the ACA. It therefore is helpful to understand the range of consumer protections in the states before the ACA, and why the ACA included the insurance reforms it did. This issue brief summarizes state rules for the individual market on the eve of the Affordable Care Act.

Issue: Republicans in Congress are expected to repeal portions of the Affordable Care Act (ACA) using a fast-track process known as budget reconciliation.
Goals: This issue brief examines how repeal legislation could affect Medicaid, the nation's health care safety net, which insured 70 million people in 2016.
Findings and Conclusions: Partial-repeal legislation that passed Congress but was vetoed by President Obama in 2016 offers some insight but new legislation could go further. It could repeal the ACA's Medicaid eligibility expansions for adults and children but also roll back other provisions, such as simplified enrollment and improvements in long-term services and supports for beneficiaries with disabilities. Additionally, the Trump Administration could expand use of demonstration authority to introduce deeper structural changes into Medicaid, such as eligibility restrictions tied to work, required premium contributions and lock-out for nonpayment, annual enrollment periods, and coverage limits and exclusions. Together, these changes would have far-reaching implications for Medicaid's continued role as the nation's safety-net insurer.

Issue: The incoming Trump administration and Republicans in Congress are seeking to repeal the Affordable Care Act (ACA), likely beginning with the law's insurance premium tax credits and expansion of Medicaid eligibility. Research shows that the loss of these two provisions would lead to a doubling of the number of uninsured, higher uncompensated care costs for providers, and higher taxes for low-income Americans.
Goal: To determine the state-by-state effect of repeal on employment and economic activity. Methods: A multistate economic forecasting model (PI+ from Regional Economic Models, Inc.) was used to quantify for each state the effects of the federal spending cuts.
Findings and Conclusions: Repeal results in a $140 billion loss in federal funding for health care in 2019, leading to the loss of 2.6 million jobs (mostly in the private sector) that year across all states. A third of lost jobs are in health care, with the majority in other industries. If replacement policies are not in place, there will be a cumulative $1.5 trillion loss in gross state products and a $2.6 trillion reduction in business output from 2019 to 2023. States and health care providers will be particularly hard hit by the funding cuts.

Issue: While the number of uninsured has decreased substantially since the Affordable Care Act (ACA) expanded coverage in 2014, questions remain about how much the economic recovery and other changes might have influenced this decline. Goal: Assess the direct impact of the ACA marketplaces and the Medicaid expansion on the uninsured rate among nonelderly adults. Methods: Analysis of insurance coverage rates before and after the ACAís first open enrollment period (fall 2013 to spring 2014) using the National Health Interview Survey (NHIS) and the Behavioral Risk Factor Surveillance Survey (BRFSS). Key findings: Based on NHIS data, enrollment in ACA-related coverage options explains about 76 percent of the 4-percentage-point decline in the uninsured rate during the first open enrollment period. Marketplace enrollments reduced the adult uninsured rate by an estimated 1.7 percentage points to 2.3 percentage points. The effects were substantially more pronounced among adults eligible for income-related subsidies. Medicaid expansions in participating states further reduced the uninsured rate by an estimated 0.76 points to 1.0 points. Conclusion: The great majority of nonelderly adults who enrolled during the first open enrollment period would likely not have held health coverage without the ACA expansions.

Since the implementation of the Affordable Care Act (ACA) in 2014, the uninsured rate in California dropped by nearly half, from 16% in 2013 to 9% in 2015. However, 2.9 million Californians remained uninsured.
California's Uninsured: As Coverage Grows, Millions Go Without provides a look at the uninsured two years after full implementation of the ACA. There could be big changes in health insurance coverage ahead with the election of President Donald Trump.
Key findings include:
The drop in the uninsured rate was mainly due to a seven percentage point increase in individually purchased insurance coupled with a five percentage point increase in Medi-Cal enrollment.
One in three of California's uninsured had annual incomes of less than $25,000. At this income level, people are potentially eligible for Medi-Cal.
Of the state's remaining uninsured, one in four were age 25 to 34, one in three were noncitizens, and more than half were Latino.
62% of the uninsured were employed. Of the 1.8 million uninsured workers, 44% worked in firms with fewer than 50 employees.
Fewer Californians cited "lack of affordability" as the main reason for going without health insurance in 2015 compared to 2014.

The 2016 election of Donald Trump as president, combined with a Republican-controlled Congress, could result in a partial or complete repeal of the Affordable Care Act (ACA). Here is a reminder of what has been achieved under the ACA -- and what California now stands to lose.
Nationally, the uninsured rate is at a historic low:
20 million Americans are covered as a result of the ACA.
Close to 90% of all Americans are now covered: The uninsured rate fell from 16.6% in 2013 to a historic low of 10.5% in 2015.
Some of the ACA's biggest gains have been in California:
Over 5 million Californians have insurance as a result of the ACA -- roughly a quarter of all Americans covered under the law.
91% of Californians are now insured. The uninsured rate in California fell from 17.2% in 2013 to a historic low of 8.6% in 2015.
In California, the uninsured rate dropped across all racial/ethnic groups, with the greatest gains seen among Latinos. Between 2013 and 2015, 1.5 million additional Latinos gained coverage, and the uninsured rate in this population fell from 23% to 12%.
The sources of coverage for the more than 5 million Californians insured under the ACA include:
1.4 million bought insurance on Covered California.
3.7 million Californians enrolled in Medi-Cal under the ACA expansion -- representing more than a quarter of the 13.6 million Californians now covered under Medi-Cal.
Hundreds of thousands of young adults under the age of 26 were able to stay on their parents' plan.
Over 1 million Californians receive financial assistance to afford coverage through Covered California:
Of Covered California's 1.4 million consumers, 1.2 million receive federal subsidies to help them pay their monthly premiums.
The average federal premium subsidy per household is $438/month.
The California Health Care Foundation will work to protect the coverage and access to care that millions of Californians have gained under the ACA. We remain committed to building a health care system that works for all Californians.

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